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Runway Excursion During Landing, Delta Air Lines Flight 1086, Boeing MD-88, N909DL, New York, New York, March 5, 2015

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Runway Excursion During Landing, Delta Air Lines Flight 1086, Boeing MD-88, N909DL, New York, New York, March 5, 2015 Runway Excursion During Landing Delta Air Lines Flight 1086 Boeing MD-88, N909DL New York, New York March 5, 2015 Accident Report NTSB/AAR-16/02 National PB2016-104166 Transportation Safety Board NTSB/AAR-16/02 PB2016-104166 Notation 8780 Adopted September 13, 2016 Aircraft Accident Report Runway Excursion During Landing Delta Air Lines Flight 1086 Boeing MD-88, N909DL New York, New York March 5, 2015 National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 National Transportation Safety Board. 2016. Runway Excursion During Landing, Delta Air Lines Flight 1086, Boeing MD-88, N909DL, New York, New York, March 5, 2015. Aircraft Accident Report NTSB/AAR-16/02. Washington, DC. Abstract: This report discusses the March 5, 2015, accident in which Delta Air Lines flight 1086, a Boeing MD-88 airplane, N909DL, was landing on runway 13 at LaGuardia Airport, New York, New York, when it departed the left side of the runway, contacted the airport perimeter fence, and came to rest with the airplane’s nose on an embankment next to Flushing Bay. The 2 pilots, 3 flight attendants, and 98 of the 127 passengers were not injured; the other 29 passengers received minor injuries. The airplane was substantially damaged. Safety issues discussed in the report relate to the use of excessive engine reverse thrust and rudder blanking on MD-80 series airplanes, the subjective nature of braking action reports, the lack of procedures for crew communications during an emergency or a non-normal event without operative communication systems, inaccurate passenger counts provided to emergency responders following an accident, and unclear policies regarding runway friction measurements and runway condition reporting. Safety recommendations are addressed to the Federal Aviation Administration, Boeing, US operators of MD-80 series airplanes, and the Port Authority of New York and New Jersey. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Internet at <http://www.ntsb.gov>. Other information about available publications also may be obtained from the website or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2016-104166 from: National Technical Information Service 5301 Shawnee Road Alexandria, Virginia 22312 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. NTSB Aircraft Accident Report Contents Figures ........................................................................................................................................... iii Tables ............................................................................................................................................ iv Abbreviations and Acronyms .......................................................................................................v Executive Summary ................................................................................................................... viii 1. Factual Information ...................................................................................................................1 1.1 History of Flight .........................................................................................................................1 1.2 Personnel Information ..............................................................................................................10 1.2.1 The Captain ....................................................................................................................10 1.2.2 The First Officer ............................................................................................................11 1.2.3 The Flight Attendants ....................................................................................................12 1.3 Airplane Information ...............................................................................................................13 1.3.1 Thrust Reverser System .................................................................................................13 1.3.2 Braking System ..............................................................................................................16 1.3.3 Spoiler System ...............................................................................................................16 1.3.4 Postaccident Examination of N909DL ..........................................................................17 1.4 Meteorological Information .....................................................................................................18 1.5 Airport Information ..................................................................................................................19 1.5.1 Airport Snow Operations on the Day of the Accident ...................................................19 1.5.2 Runway Condition Reports ............................................................................................21 1.5.3 Runway Friction Assessments .......................................................................................22 1.6 Flight Recorders .......................................................................................................................24 1.7 Survival Aspects ......................................................................................................................24 1.7.1 Evacuation .....................................................................................................................24 1.7.2 Emergency Response .....................................................................................................28 1.8 Tests and Research: Aircraft Performance Study ....................................................................29 1.8.1 Loss of Directional Control ...........................................................................................30 1.8.2 Comparison of Preceding Flight and Accident Flight ...................................................31 1.8.3 Engine Pressure Ratio Levels During Other Landings ..................................................32 1.9 Organizational and Management Information .........................................................................33 1.9.1 Flight Crew Manuals and Guidance ..............................................................................33 1.9.2 Flight Crew Training .....................................................................................................36 1.9.3 Flight Attendant Manual ................................................................................................37 1.9.4 Flight Attendant Training ..............................................................................................38 1.10 Additional Information ..........................................................................................................38 1.10.1 Runway Excursion Events ...........................................................................................38 1.10.2 Takeoff and Landing Performance Assessment Aviation Rulemaking Committee ...............................................................................................................................39 1.10.3 Previous Safety Recommendations .............................................................................41 i NTSB Aircraft Accident Report 2. Analysis .....................................................................................................................................47 2.1 Accident Sequence ...................................................................................................................47 2.1.1 General ...........................................................................................................................47 2.1.2 Preflight Activities .........................................................................................................47 2.1.3 En Route Preparations and Decision-making ................................................................48 2.1.4 The Approach ................................................................................................................50 2.1.5 The Landing ...................................................................................................................51 2.2 Mitigations to Preclude Excessive Reverse Thrust Use ..........................................................55
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